First hemodialysis access selection varies with patient acuity

Area of Science:

• Nephrology
• Vascular Surgery
• Public Health

Background:

• National Kidney Foundation Dialysis Outcomes Quality Improvement (NKF-DOQI) guidelines recommend native arteriovenous (AV) fistulae as the preferred vascular access for hemodialysis patients.
• The course of progression to end-stage renal disease (ESRD) may influence the selection of initial vascular access.

Purpose of the Study:

• To investigate if patients' clinical course to ESRD affected the selection of initial hemodialysis vascular access.
• To assess the adequacy of initial vascular access in different patient groups.

Main Methods:

• A retrospective study of 240 incident hemodialysis patients from 6 centers in Network One's Vascular Access Quality Improvement Project (QIP).
• Patients were categorized into three groups: KNOWN (predictable progression), CRISIS (unanticipated medical crisis), and UNKNOWN (undiagnosed chronic renal insufficiency).
• Initial vascular access types (fistula, graft, catheter) and their functionality at 2 months were analyzed.

Main Results:

• Only 43% of patients had a predictable progression to ESRD.
• The most frequent initial access was a catheter (54%), followed by fistula (29%) and graft (16%).
• KNOWN patients were significantly more likely to receive a fistula (46%) compared to CRISIS or UNKNOWN patients (P <.001). Initial access supported dialysis in 53.7% of KNOWN, 59.4% of CRISIS, and 45.7% of UNKNOWN patients after 2 months.

Conclusions:

• Unpredicted onset of ESRD is common, with these patients less likely to receive a preferred AV fistula.
• Current vascular access selection practices may not adequately address the needs of patients with unforeseen dialysis requirements.
• Further research is needed to define optimal vascular access management strategies for patients with emergent dialysis needs.